Impact of frailty scores on outcome of octogenarian patients undergoing transcatheter aortic valve implantation

Estimated prevalence of frailty and prefrailty in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and proportional meta-analysis

BACKGROUND

The aging population has led to an increasing number of older patients undergoing cardiac surgeries/procedures. Frailty and prefrailty have emerged as important prognostic indicators among these patients. This proportional meta-analysis estimated the prevalence of frailty and prefrailty among patients undergoing cardiac surgery.

METHODS

We searched seven electronic databases for observational studies that used validated measure(s) of frailty and reported prevalence data on frailty and/or prefrailty in older patients undergoing coronary artery or valvular surgeries or transcatheter procedures. Meta-analyses were performed using a random-effects model.

RESULTS

One hundred and one articles involving 626,863 patients were included. The pooled prevalence rates of frailty and prefrailty were 28% (95% confidence interval [CI]: 23%-33%) and 40% (95% CI: 31%-50%), respectively, for patients scheduled for open-heart surgeries and 40% (95% CI: 36%-45%) and 43% (95% CI: 34%-53%), respectively, for patients undergoing transcatheter procedures. Frailty measured using a multidimensional approach identified a higher proportion of frail patients when compared with measures solely focused on physical frailty. Older age, female sex, and lower body mass index and hemoglobin concentrations were significantly associated with higher frailty prevalence. Moreover, countries with higher gross domestic product spent on healthcare exhibited a higher frailty prevalence.

CONCLUSION

Frailty represents a considerable health challenge among patients undergoing cardiac surgeries/procedures. Routine screening for frailty should be considered during perioperative care planning.

Progression of Frailty and Cardiovascular Outcomes Among Medicare Beneficiaries

Background

Frailty is associated with adverse cardiovascular outcomes independent of age and comorbidities, yet the independent influence of frailty progression remains uncertain.

Methods

Medicare Fee-for-service beneficiaries ≥ 65 years at cohort inception with continuous enrollment from 2003-2015 were included. Frailty trajectory was measured by annualized change in a validated claims-based frailty index (CFI) over a 5-year period. Linear mixed effects models, adjusting for baseline frailty, were used to estimate CFI change over a 5-year period. Survival analysis was used to evaluate associations of frailty progression and future health outcomes (major adverse cardiovascular and cerebrovascular events [MACCE], all-cause death, heart failure, myocardial infarction, ischemic stroke, and days alive at home [DAH] within the following calendar year).

Results

26.4 million unique beneficiaries were included (mean age 75.4 ± 7.0 years, 57% female, 13% non-White). In total, 20% had frailty progression, 66% had no change in frailty, and 14% frailty regression over median follow-up of 2.4 years. Compared to those without a change in CFI, when adjusting for baseline frailty, those with frailty progression had significantly greater risk of incident MACCE (hazard ratio [HR] 2.30, 95% confidence interval [CI] 2.30-2.31), all-cause mortality (HR 1.59, 95% CI 1.58-1.59), acute myocardial infarction (HR 1.78, 95% CI 1.77-1.79), heart failure (HR 2.78, 95% CI 2.77-2.79), and stroke (HR 1.78, 95% CI 1.77-1.79). There was also a graded increase in risk of each outcome with more rapid progression and significantly fewer DAH with the most rapid vs. the slowest progression group (270.4 ± 112.3 vs. 308.6 ± 93.0 days, rate ratio 0.88, 95% CI 0.87-0.88, p < 0.001).

Conclusions

In this large, nationwide sample of Medicare beneficiaries, frailty progression, independent of baseline frailty, was associated with fewer DAH and a graded risk of MACCE, all-cause mortality, myocardial infarction, heart failure, and stroke compared to those without progression.

The prognostic impacts of frailty on clinical and patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and meta-analysis

BACKGROUND

Frailty is emerging as an important prognostic indicator for patients undergoing cardiac surgeries/procedures. We sought to evaluate the prognostic and differential impacts of frailty on patients undergoing coronary artery or valvular surgical procedures of different levels of invasiveness, and to explore the differential predictability of various frailty measurement models.

METHODS

Eight databases were searched for prospective cohort studies that have adopted validated measure(s) of frailty and reported clinical, healthcare service utilization, or patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures.

RESULTS

Sixty-two articles were included (N = 16,679). Frailty significantly predicted mortality (short-term [≤ 30 days]: odds ratio [OR]: 2.33, 95% confidence interval [CI]: 1.28-4.26; midterm [6 months to 1 year]: OR: 3.93, 95%CI: 2.65-5.83; long-term [>1 year]: HR: 2.23, 95%CI: 1.60-3.11), postoperative complications (ORs: 2.54-3.57), discharge to care facilities (OR: 5.52, 95%CI: 3.84-7.94), hospital readmission (OR: 2.00, 95%CI: 1.15-3.50), and reduced health-related quality of life (HRQoL; standardized mean difference: -0.74, 95%CI: -1.30 to -0.18). Subgroup analyses showed that frailty exerted a greater impact on short-term mortality in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional and physical-aspect-focused frailty measurements performed equally in predicting mortality, but multidimensional measurements were more predictive of hospital readmission than physical-aspect-focused measurements.

CONCLUSION

Frailty was predictive of postoperative mortality, complications, increased healthcare service utilization, and reduced HRQoL. The impact of frailty on short-term mortality was more prominent in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional measures of frailty enhanced prognostic risk estimation, especially for hospital readmission.

Effect of BMI on patients undergoing transcatheter aortic valve implantation: A systematic review and meta-analysis

BACKGROUND

The relationship of body mass index (BMI) and an "obesity paradox" with cardiovascular risk prediction is controversial. This systematic review and meta-analysis aims to compare the associations of different BMI ranges on transcatheter aortic valve implantation (TAVI) outcomes.

METHODS

International databases, including PubMed, the Web of Science, and the Cochrane Library, were systematically searched for observational and randomized controlled trial studies investigating TAVI outcomes in any of the four BMI categories: underweight, normal weight, overweight, and obese with one of the predefined outcomes. Primary outcomes were in-hospital, 30-day, and long-term all-cause mortality. Random-effects meta-analysis was performed to calculate the odds ratio (OR) or standardized mean differences (SMD) with 95% confidence interval (CI) for each paired comparison between two of the BMI categories.

RESULTS

A total of 38 studies were included in our analysis, investigating 99,829 patients undergoing TAVI. There was a trend toward higher comorbidities such as hypertension, diabetes, and dyslipidemia in overweight patients and individuals with obesity. Compared with normal-weight, patients with obesity had a lower rate of 30-day mortality (OR 0.42, 95% CI 0.25-0.72, p < 0.01), paravalvular aortic regurgitation (OR 0.63, 95% CI 0.44-0.91, p = 0.01), 1-year mortality (OR 0.48, 95% CI 0.24-0.96, p = 0.04), and long-term mortality (OR 0.69, 95% CI 0.51-0.94, p = 0.02). However, acute kidney injury (OR 1.16, 95% CI 1.04-1.30, p = 0.01) and permanent pacemaker implantation (OR 1.25, 95% CI 1.05-1.50, p = 0.01) odds were higher in patients with obesity. Noteworthy, major vascular complications were significantly higher in underweight patients in comparison with normal weight cases (OR 1.62, 95% CI 1.07-2.46, p = 0.02). In terms of left ventricular ejection fraction (LVEF), patients with obesity had higher post-operative LVEF compared to normal-weight individuals (SMD 0.12, 95% CI 0.02-0.22, p = 0.02).

CONCLUSION

Our results suggest the presence of the "obesity paradox" in TAVI outcomes with higher BMI ranges being associated with lower short- and long-term mortality. BMI can be utilized for risk prediction of patients undergoing TAVI.

C-Reactive Protein to Albumin Ratio in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVE

To evaluate whether the serum C-reactive protein to albumin ratio (CAR) could be used for risk stratification of patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS).

PATIENTS AND METHODS

Frailty is a predictor of poor outcomes in patients undergoing AS interventions. The CAR reflects key components of frailty (systemic inflammation and nutrition) and could potentially be implemented into assessment and management strategies for patients with AS. From March 1, 2010, through February 29, 2020, 1836 patients were prospectively enrolled in an observational TAVR database. Patients (prospective development cohort, n=763) were grouped into CAR quartiles to compare the upper quartile (CAR Q4) with the lower quartiles (CAR Q1-3). Primary end point was all-cause mortality. Results were verified in an independent retrospective cohort (n=1403).

RESULTS

The CAR Q4 had a higher prevalence of impaired left ventricular function, atrial fibrillation, diabetes, and cerebrovascular disease and a higher median logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) vs CAR Q1-3. After median follow-up of 15.0 months, all-cause mortality was significantly higher in CAR Q4 vs CAR Q1-3 (P<.001). In multivariable analyses, risk factors for all-cause mortality were CAR Q4 (>0.1632; hazard ratio, 1.45; 95% confidence interval, 1.05 to 2.00; P=.03), N-terminal pro-B-type natriuretic peptide Q4 (>3230 pg/mL [to convert to ng/L, multiply by 1), high-sensitivity troponin T Q4 (>0.0395 ng/mL [to convert to μg/L, multiply by 1]), above-median logistic EuroSCORE (16.1%), myocardial infarction, Acute Kidney Injury Network stage 3, and life-threatening bleeding.

CONCLUSION

Elevated CAR was associated with increased risk of all-cause mortality in patients undergoing transfemoral TAVR. The CAR, a simple, objective tool to assess frailty, could be incorporated into assessing patients with AS being considered for TAVR.

Five-Meter Walk Test as a Predictor of Prolonged Index Hospitalization After Transcatheter Aortic Valve Implantation

There are no studies evaluating comprehensive predictors of transcatheter aortic valve implantation (TAVI) outcomes encompassing frailty assessments in a South-East Asian cohort. In this longitudinal single-center cohort, all patients who underwent TAVI in a tertiary cardiac center and comprehensively assessed for frailty at baseline were included in a registry. The primary outcome was to investigate frailty indices predictive of prolonged index hospitalization after TAVI. Seventy-six patients with a mean age of 77.6 ± 8.5 years were included. Mean Society of Thoracic Society Predicted Risk of Mortality score was 5.2 ± 3.0, with 11 (14.5%) patients classified as high-risk (Society of Thoracic Society Predicted Risk of Mortality >8). Mean and median index hospitalization duration were 9.2 ± 5.6 and 7 [4.5 to 9.5] days, respectively. Univariate analysis demonstrated that lower hemoglobin (Hb) (p <0.01), longer 5-meter walk test (5MWT) (p <0.01), lower dominant hand grip strength (p <0.01), the use of transaortic access (p = 0.01), new atrial fibrillation post-TAVI (p <0.01), and lower postprocedural Hb (p <0.01) were associated with longer index hospitalization duration. Multivariate linear regression demonstrated preoperative Hb, preoperative atrial fibrillation and 5MWT were independent baseline predictors of index hospitalization duration (p <0.05). Additionally, a 5MWT cutoff of 11 seconds (0.45 m/s) had a high specificity (88.6%) in predicting prolonged index hospitalization duration. In conclusion, this is the first comprehensive frailty assessment in a South-East Asian cohort demonstrating 5MWT to be a significant predictor of prolonged index hospitalization. This simple and effective frailty assessment index may be considered to optimize patient selection for TAVI.

Prevalence and Prognostic Implications of Frailty in Transcatheter Aortic Valve Replacement

Assessment of frailty has become engrained in the preprocedural evaluation of older adults referred for transcatheter aortic valve replacement. Addition of frailty and disability to clinical risk scores results in improved discrimination for short- and midterm mortality and identifies patients less likely to be discharged home and more likely to report worsening quality of life over the ensuing 6 to 12 months. In clinical practice, frailty can be evaluated by a tiered approach starting with a brief screening tool such as the Essential Frailty Toolset.

Comprehensive Geriatric Assessment in Cardiovascular Disease

Frailty and cardiovascular disease (CVD) are both highly prevalent in older adults. Cardiovascular disease has been identified as the most frequent cause of death, while frailty has been identified as one of geriatric giants characterized by decreased physiological reserves and increased vulnerability. However, the exact pathobiological links between the two conditions have not been fully elucidated. Consequently, we observe a relevant difficulty not only in accurately defining cardiovascular risk in vulnerable elderly patients (and the other way around), but also a lack of consensus regarding CVD management in the very old. Nowadays, considering the enormous technical innovation, many elderly patients, if appropriately selected, could be eligible even for the most complex treatments, including invasive cardiological procedures. Identification of frail patients at risk of negative outcomes can allow the customization of therapeutic interventions in elderly patients with CVD, allowing the elderly who can benefit from them to undergo even invasive procedures and avoiding futile or dangerous treatments for the most vulnerable patients. A large number of tools and definitions for assessing frailty have been proposed; different scales and assessment tools can be useful for different purposes, but at present there is no clear indication for their use in CVD. In this chapter, we will describe the main geriatric approach to ascertain frailty, the assessment tools used in patients with cardiovascular diseases, and propose an operational strategy to evaluate frailty and identify patients eligible for pharmacologic or surgical interventions.

The value of screening for cognition, depression, and frailty in patients referred for TAVI

Background: Current surgical risk assessment tools fall short of appreciating geriatric risk factors including cognitive deficits, depressive, and frailty symptoms that may worsen outcomes post-transcatheter aortic valve implantation (TAVI). This study hypothesized that a screening tool, SMARTIE, would improve detection of these risks pre-TAVI, and thus be predictive of postoperative delirium (POD) and 30-day mortality post-TAVI. Design: Prospective observational cohort study, using a historical cohort for comparison. Participants: A total of 234 patients (age: 82.2±6.7 years, 59.4% male) were included. Half were screened using SMARTIE. Methods: The SMARTIE cohort was assessed for cognitive deficits and depressive symptoms using the Mini-Cog test and PHQ-2, respectively. Measures of frailty included activities of daily living inventory, the Timed Up and Go test and grip strength. For the pre-SMARTIE cohort, we extracted cognitive deficits, depression and frailty symptoms from clinic charts. The incidence of POD and 30-day mortality were recorded. Bivariate chi-square analysis or t-tests were used to report associations between SMARTIE and pre-SMARTIE groups. Multivariable logistic regression models were employed to identify independent predictors of POD and 30-day mortality. Results: More patients were identified with cognitive deficits (χ2=11.73, p=0.001), depressive symptoms (χ2=8.15, p=0.004), and physical frailty (χ2=5.73, p=0.017) using SMARTIE. Cognitive deficits were an independent predictor of POD (OR: 8.4, p<0.01) and 30-day mortality (OR: 4.04, p=0.03). Conclusion: This study emphasized the value of screening for geriatric risk factors prior to TAVI by demonstrating that screening increased identification of at-risk patients. It also confirmed findings that cognitive deficits are predictive of POD and mortality following TAVI.

The impact of preoperative frailty status on outcomes after transcatheter aortic valve replacement: An update of systematic review and meta-analysis

BACKGROUND

Frailty is a syndrome of impaired physiologic reserve and decreased resistance to stressors and can often be seen in high-risk patients undergoing transcatheter aortic valve replacement (TAVR). Preoperative frailty status is thought to be related to adverse outcomes after TAVR. We conducted this systematic review and meta-analysis to determine the impact of preoperative frailty status on outcomes among patients after TAVR.

METHODS

PubMed, Embase, and the Cochrane Library were searched for relevant studies through January 2018. Fourteen articles (n = 7489) meeting the inclusion criteria were finally included. Possible effects were calculated using meta-analysis.

RESULTS

The pooled risk ratios (RRs) of late mortality (>6 months) and acute kidney injury after TAVR in frail group were 2.81 (95% confidence interval (CI) 1.90-4.15, P < .001, I = 84%) and 1.41 (95% CI 1.02-1.94, P = .04, I = 24%), respectively. Compared with non-frail group, significantly higher incidence of 30-day mortality (RR 2.03, 95% CI 1.63-2.54, P < .001, I = 0%) and life threatening or major bleeding after TAVR (RR 1.48, 95% CI 1.20-1.82, P < .001, I = 14%) was found in frail group. There was no significant association between frailty and incidence of stroke after TAVR (RR 0.93, 95% CI 0.53-1.63, P = .80, I = 0%).

CONCLUSION

Preoperative frailty status is proved to be significantly associated with poor outcomes after TAVR. Our findings may remind doctors in the field of a more comprehensive preoperative evaluation for TAVR candidates. More well-designed and large-sample sized prospective studies are further needed to figure out the best frailty assessment tool for patients undergoing TAVR.

The relationship between preoperative frailty and outcomes following transcatheter aortic valve implantation: a systematic review and meta-analysis

Aims

Transcatheter aortic valve implantation (TAVI) is an increasingly common intervention for patients with aortic stenosis deemed high risk for major cardiac surgery, but identifying those who will benefit can be challenging. Frailty reflects physiological reserve and may be a useful prognostic marker in this population. We performed a systematic review and meta-analysis of the association between frailty and outcomes after TAVI.

Methods and Results

Five databases were searched between January 2000 and May 2015. From 2623 articles screened, 54 were assessed for eligibility. Ten cohort studies (n = 4592) met the inclusion criteria of reporting a measure of frailty with early (≤30 days) or late (>30 days) mortality and procedural complications following TAVI as defined by the Valve Academic Research Consortium (VARC). Frailty was associated with increased early mortality in four studies (n = 1900) (HR 2.35, 95% CI 1.78–3.09, P < 0.001) and increased late mortality in seven studies (n = 3159) (HR 1.63, 95% CI 1.34–1.97, P < 0.001). Objective frailty tools identified an even higher risk group for late mortality (HR 2.63, 95% CI 1.87–3.70, P < 0.001). Frail individuals undergoing TAVI have a mortality rate of 34 deaths per 100 patient years, compared with 19 deaths per 100 patient years in non-frail patients. There was limited reporting of VARC procedural outcomes in relation to frailty, preventing meta-analysis.

Conclusion

Frailty assessment in an already vulnerable TAVI population identifies individuals at even greater risk of poor outcomes. Use of objective frailty tools may inform patient selection, but this requires further assessment in large prospective registries.

Frailty and Exercise Training: How to Provide Best Care after Cardiac Surgery or Intervention for Elder Patients with Valvular Heart Disease

The aim of this literature review was to evaluate existing evidence on exercise-based cardiac rehabilitation (CR) as a treatment option for elderly frail patients with valvular heart disease (VHD). Pubmed database was searched for articles between 1980 and January 2018. From 2623 articles screened, 61 on frailty and VHD and 12 on exercise-based training for patients with VHD were included in the analysis. We studied and described frailty assessment in this patient population. Studies reporting results of exercise training in patients after surgical/interventional VHD treatment were analyzed regarding contents and outcomes. The tools for frailty assessment included fried phenotype frailty index and its modifications, multidimensional geriatric assessment, clinical frailty scale, 5-meter walking test, serum albumin levels, and Katz index of activities of daily living. Frailty assessment in CR settings should be based on functional, objective tests and should have similar components as tools for risk assessment (mobility, muscle mass and strength, independence in daily living, cognitive functions, nutrition, and anxiety and depression evaluation). Participating in comprehensive exercise-based CR could improve short- and long-term outcomes (better quality of life, physical and functional capacity) in frail VHD patients. Such CR program should be led by cardiologist, and its content should include (1) exercise training (endurance and strength training to improve muscle mass, strength, balance, and coordination), (2) nutrition counseling, (3) occupational therapy (to improve independency and cognitive function), (4) psychological counseling to ensure psychosocial health, and (5) social worker counseling (to improve independency). Comprehensive CR could help to prevent, restore, and reduce the severity of frailty as well as to improve outcomes for frail VHD patients after surgery or intervention.

Comprehensive geriatric assessment in patients undergoing transcatheter aortic valve implantation - results from the CGA-TAVI multicentre registry

Background

In older patients with aortic stenosis (AS) undergoing TAVI, the potential role of prior CGA is not well established. To explore the value of comprehensive geriatric assessment (CGA) for predicting mortality and/or hospitalisation within the first 3 months after transcatheter aortic valve implantation (TAVI).

Methods

An international, multi-centre, prospective registry (CGA-TAVI) was established to gather data on CGA results and medium-term outcomes in geriatric patients undergoing TAVI. Logistic regression was used to evaluate the predictive value of a multidimensional prognostic index (MPI); a short physical performance battery (SPPB); and the Silver Code, which was based on administrative data, for predicting death and/or hospitalisation in the first 3 months after TAVI (primary endpoint).

Results

A total of 71 TAVI patients (mean age 85.4 years; mean log EuroSCORE I 22.5%) were enrolled. Device success according to VARC criteria was 100%. After adjustment for selected baseline characteristics, a higher (poorer) MPI score (OR: 3.34; 95% CI: 1.39–8.02; p = 0.0068) and a lower (poorer) SPPB score (OR: 1.15; 95% CI: 1.01–1.54; p = 0.0380) were found to be associated with an increased likelihood of the primary endpoint. The Silver Code did not show any predictive ability in this population.

Conclusions

Several aspects of the CGA have shown promise for being of use to physicians when predicting TAVI outcomes. While the MPI may be useful in clinical practice, the SPPB may be of particular value, being simple and quick to perform. Validation of these findings in a larger sample is warranted.

Trial registration

The trial was registered in ClinicalTrials.gov on November 7, 2013 (NCT01991444).

Transcatheter aortic valve implantation: where are we now?

Transcatheter aortic valve implantation (TAVI) was first used in clinical practice in 2002. Since 2002, there has been a rapid increase in TAVI activity in patients with symptomatic severe aortic stenosis. This has been supported by systematic randomized data comparing TAVI against the gold standard treatment for the last 50 years’ surgical aortic valve replacement. TAVI is now currently a recommended therapeutic intervention in the treatment of severe aortic stenosis patients who are deemed either high risk or inoperable. The indications for TAVI continue to expand. Within this review we will focus on the current guidelines for TAVI, the evidence for it, the complications of TAVI, postprocedure care, the technology available to clinicians now and finally the future perspectives for TAVI.

Addition of albumin to Traditional Risk Score Improved Prediction of Mortality in Individuals Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVES

The ability of the Society of Thoracic Surgeons (STS) and European System for Cardiac Operative Risk Evaluation (EuroSCORE)-2 scores to predict outcomes after transcatheter aortic valve replacement (TAVR) is insufficient. Frailty and serum albumin as a frailty marker were shown to correlate with prognosis after TAVR. We sought to evaluate the additive value of serum albumin to STS and EuroSCORE-2 scores to predict mortality in individuals undergoing TAVR.

DESIGN

Retrospective analysis.

SETTING

Tertiary-care hospital prospective registry.

PARTICIPANTS

Individuals who underwent TAVR (N = 426).

MEASUREMENTS

We compared survival rates according to median baseline albumin levels (4 g/dL), STS score (4.5%), and EuroSCORE-2 (3.45%). Participants were divided into four groups according to median serum albumin and median STS and EuroSCORE-2 scores (high vs low), and 1-year survival rates were compared. A category-free net reclassification index (NRI) was calculated to compare the ability of a model of STS or EuroSCORE-2 alone to classify mortality risk with and without the addition of baseline serum albumin.

RESULTS

Participants with low albumin levels had higher mortality (hazard ratio (HR) = 3.03, 95% confidence interval (CI) = 1.66-5.26, P < .001). Participants with low serum albumin and a high STS (HR = 4.55, 95% CI = 2.21-9.38, P < .001) or EuroSCORE-2 (HR = 2.72, 95% CI = 1.48-5.06, P = .001) score had higher mortality. Using NRI analysis, a model that included albumin in addition to STS correctly reclassified 42% of events (NRI = 0.58) and a model that included albumin in addition to EuroSCORE-2 correctly reclassified 44% of events (NRI = 0.64).

CONCLUSION

Serum albumin, as a marker of frailty, can significantly improve the ability of STS and EuroSCORE-2 scores to predict TAVR-related mortality.

Causes and temporal trends in procedural deaths after transcatheter aortic valve implantation

BACKGROUND

The causes of procedural deaths after transcatheter aortic valve implantation (TAVI) have been scarcely detailed.

AIMS

To assess these causes and their temporal trends since the beginning of the TAVI era.

METHODS

From October 2006 to April 2014, 601 consecutive high-risk/inoperable patients with severe aortic stenosis underwent TAVI using the Edwards SAPIEN or SAPIEN XT or the Medtronic CoreValve. The transfemoral route was the default approach; the transapical or left subclavian approaches were alternative options. Patients were divided into three tertiles according to the date of the procedure.

RESULTS

Procedural death occurred in 45 patients (7.5%), with a median±standard deviation age of 83±7 years; 23 were men (51%) and the mean logistic EuroSCORE was 26±16%. The main cause of death was heart failure (n=19, 42%), followed by cardiac rupture (n=12, 27%), intensive care complications (n=9, 20%) and vascular complications (n=5, 11%). The mortality rate was higher after transapical than transfemoral TAVI (17% vs. 5%; P<0.001). The mortality rate decreased over time (11.9% in the first tertile, 6.0% in the second and 4.5% in the third [P=0.007]), driven by a reduction in heart failure-related deaths (6.5% in the first tertile vs. 1.5% in the third; P=0.011). Vascular complication-related deaths disappeared in the third tertile. However, there was no decrease in deaths related to cardiac ruptures and intensive care complications.

CONCLUSIONS

The procedural mortality rate of TAVI decreased over time, driven by the decrease in heart failure-related deaths. However, efforts should continue to prevent cardiac ruptures and improve the outcomes of patients requiring intensive care after TAVI.

The impact of frailty on mortality after transcatheter aortic valve replacement

Frailty is a notably common problem in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) evaluation. Studies have demonstrated significant associations between frailty and worse outcomes in patients undergoing TAVR including higher risks of disability and mortality and admissions to long-term care facility. While there are multiple methods to identify and measure frailty, there is a critical need for a precise definition of frailty and its standardized assessment protocol based on well-established tests covering all aspects of the frailty, as a syndrome. Incorporation of the available frailty evaluation into pre-operative risk assessments chances of morbidity or mortality following surgery can help enhancing performance and improve shared decision-making between physicians and their patients. In this review, we present the perspectives of the impact of frailty on mortality in patients undergoing TAVR.

Impact of frailty on mortality after transcatheter aortic valve implantation

BACKGROUND

We sought to investigate the relation between frailty indices and 12-month mortality after transcatheter aortic valve implantation (TAVI).

METHODS

We included 101 consecutive patients with severe aortic stenosis who have undergone TAVI. Frailty indices according to Valve Academic Research Consortium-2 recommendations (5-m walk test [5MWT] and hand grip strength) as well as other available scales of frailty (Katz index, Elderly Mobility Scale [EMS], Canadian Study of Health and Aging [CSHA] scale, Identification of Seniors at Risk [ISAR] scale) were assessed at baseline. The primary endpoint was 12-month all-cause mortality.

RESULTS

Twelve-month all-cause mortality was 17.8%. According to 5MWT, 17.8% were frail; hand grip test: 6.9%; Katz index: 17.8%; EMS: 7.9%; CSHA scale: 16.9%; and ISAR scale: 52.5%. Associations between frailty indices and 12-month all-cause mortality after TAVI were significant in Cox regression analysis (frail vs not frail, presented as hazard ratio[95%CI] adjusted for logistic EuroSCORE): for 5MWT, 72.38 (15.95-328.44); for EMS, 23.39 (6.89-79.34); for CSHA scale, 53.97 (14.67-198.53); for Katz index, 21.69 (6.89-68.25); for hand grip strength, 51.54 (12.98-204.74); and for ISAR scale, 15.94 (2.10-120.74). Similarly, such relationship was confirmed when 5MWT, EMS, and CSHA were used as continuous variables (hazard ratio [95%CI] adjusted for logistic EuroSCORE: for 5MWT per 1-second increase, 2.55 [1.94-3.37]; for EMS per 1-point decrease, 2.90 (1.99-4.21); and for CSHA per 1-point increase, 3.13 [2.17-4.53]).

CONCLUSIONS

Our study confirmed a strong predictive ability of most of the proposed frailty indices for 12-month mortality after TAVI. For patients scheduled for TAVI, the use of frailty indices, which are easy and quick to assess on clinical basis but with strong performance, for example, 5MWT, EMS, or hand grip test, may be advocated.

Preprocedural but not periprocedural high-sensitive Troponin T levels predict outcome in patients undergoing transcatheter aortic valve implantation

AIM

Risk assessment of patients undergoing transcatheter aortic valve implantation (TAVI) remains difficult. Biomarkers have been shown to provide potential prognostic information. Here, we aimed to analyze whether the biomarker high-sensitivity Troponin T (hsTNT) could be used to improve risk stratification.

METHOD

We prospectively enrolled 267 patients undergoing TAVI. Biomarkers (hsTNT and NTproBNP) were measured 1 day before, and 3 and 7 days postprocedure. All possible prognostic factors upon survival time were analyzed by Cox regression analysis.

RESULTS

A total of 259 patients (mean age 82±6.1 years) were available for complete follow-up. The median Logistic EuroSCORE (Log ES) and Log ES II were 21.16% (Q1=13.92; Q3=34.27) and 6.42% (Q1=3.89; Q3=11.07), respectively. Median follow-up was 290 (Q1=88; Q3=529) days. A total of 71 deaths occurred during follow-up, and the 30-day mortality was 5.8%. Median baseline hsTNT was 27.4 pg/mL (Q1=16.2; Q3=46 pg/mL). From all potential mortality-associated factors, only preprocedural hsTNT level (P=.001), elevated Log ES (P=.03) as well as acute kidney injury (P<.001) and chronic obstructive pulmonary disease (COPD) (P=.039) emerged as independent prognostic parameters for adverse outcome. We also tested whether the Valve Academic Research Consortium-2 (VARC-II) cutoff for myocardial damage (hsTNT peak value exceeding 15× the upper reference limit + at least 50% increase) was of prognostic relevance. At 72-hours post-TAVI, 36.2% of the patients matched these VARC-II criteria of myocardial damage. However, these patients did not display a difference in survival compared to patients without significant myocardial injury.

CONCLUSION

Elevated preprocedural hsTNT represents an independent risk predictor of all-cause death while periprocedural hsTNT elevation failed to show prognostic relevance.

Physical frailty in older people with severe aortic stenosis

BACKGROUND

Assessment of physical frailty is important among elderly with severe aortic stenosis (AS) when considering treatment.

AIMS

We aimed to: (1) investigate the prevalence of physical frailty in older people with severe AS and (2) examine factors related to physical frailty.

METHODS

A total of 125 consecutive elderly AS patients (mean age 84.6 ± 4.4 year) were enrolled. Physical frailty was defined as scoring ≤8 points on the short physical performance battery (SPPB). Factors likely related to physical frailty, including cardiac function, nutritional and metabolic status, kidney function, medical history, and comorbidities, were evaluated. Logistic regression analyses were used to examine which factors were related to physical frailty.

RESULTS

Physical frailty was prevalent in 38.4 %. After sex and age adjusted, the following were significantly related to physical frailty: LVEF (adjusted OR per 10 % decrease: 1.39, p < 0.05), the Mini Nutritional Assessment-Short Form (adjusted OR per 1 point decrease: 1.21, p < 0.05), serum albumin (adjusted OR per 1 g/dL decrease: 2.64, p < 0.05), HDL-C (adjusted OR per 10 mg/dL decrease: 1.52, p < 0.01), eGFR (adjusted OR per 10 mL/min decrease: 1.59, p < 0.05), grip strength (adjusted OR per 10 kg decrease: 3.60, p < 0.01), coronary heart disease (adjusted OR: 2.78, p < 0.01), cerebrovascular disease (adjusted OR: 6.06, p < 0.01), and musculoskeletal disorders (adjusted OR: 3.28, p < 0.01).

CONCLUSIONS

The prevalence of physical frailty is high and related to nutritional status, comorbidities, and cardiac status.

Albumin correlates with all-cause mortality in elderly patients undergoing transcatheter aortic valve implantation

AIMS

Albumin is a marker of frailty. Scarce data are available on correlations between frailty-related parameters and outcomes in patients undergoing TAVI. This study sought to evaluate the relation between albumin and mortality in TAVI candidates.

METHODS AND RESULTS

A total of 150 patients (mean age 81±6 years) undergoing TAVI were included in the study. Patients with pre-procedural albumin >4 g/dl (>40 g/L) (n=71) were compared to those ≤4 g/dl (≤40 g/L) (n=79). The cut-off value of 4 g/dl (40 g/L) was based on the mean value of albumin in the patients included in the study. During a mean follow-up of 2.1 years the survival rate was 72%. Patients in both groups had similar baseline characteristics. The 2.1-year mortality was higher in the low albumin group compared with the normal albumin group (35% vs. 19%, p=0.01). Multivariate analysis indicated that low pre-procedural albumin was independently associated with a more than twofold increase in 2.1-year all-cause mortality (p=0.01, HR=2.28; 95% CI: 1.17-4.44). Low post-procedural serum albumin remained a strong parameter correlated with all-cause mortality (HR=2.47; 95% CI: 1.28-4.78; p<0.01).

CONCLUSIONS

Baseline albumin can be used as a simple tool that correlates with survival after TAVI. Low albumin is an important parameter associated with all-cause mortality after the procedure.

Frailty and post-operative outcomes in older surgical patients: a systematic review

Background

As the population ages, increasing numbers of older adults are undergoing surgery. Frailty is prevalent in older adults and may be a better predictor of post-operative morbidity and mortality than chronological age. The aim of this review was to examine the impact of frailty on adverse outcomes in the ‘older old’ and ‘oldest old’ surgical patients.

Methods

A systematic review was undertaken. Electronic databases from 2010 to 2015 were searched to identify articles which evaluated the relationship between frailty and post-operative outcomes in surgical populations with a mean age of 75 and older. Articles were excluded if they were in non-English languages or if frailty was measured using a single marker only. Demographic data, type of surgery performed, frailty measure and impact of frailty on adverse outcomes were extracted from the selected studies. Quality of the studies and risk of bias was assessed by the Epidemiological Appraisal Instrument.

Results

Twenty-three studies were selected for the review and they were assessed as medium to high quality. The mean age ranged from 75 to 87 years, and included patients undergoing cardiac, oncological, general, vascular and hip fracture surgeries. There were 21 different instruments used to measure frailty. Regardless of how frailty was measured, the strongest evidence in terms of numbers of studies, consistency of results and study quality was for associations between frailty and increased mortality at 30 days, 90 days and one year follow-up, post-operative complications and length of stay. A small number of studies reported on discharge to institutional care, functional decline and lower quality of life after surgery, and also found a significant association with frailty.

Conclusion

There was strong evidence that frailty in older-old and oldest-old surgical patients predicts post-operative mortality, complications, and prolonged length of stay. Frailty assessment may be a valuable tool in peri-operative assessment. It is possible that different frailty tools are best suited for different acuity and type of surgical patients. The association between frailty and return to pre-morbid function, discharge destination, and quality of life after surgery warrants further research.

Frailty Status and Outcomes After Transcatheter Aortic Valve Implantation

Frailty is a syndrome of older adults associated with increased morbidity and mortality. We aimed to assess the impact of frailty status on outcomes after transcatheter aortic valve implantation (TAVI). We reviewed all 191 patients who underwent a modified Fried frailty assessment before TAVI between February 2012 and September 2015 at a single academic medical center, and we assessed the impact of preoperative frailty status on morbidity, mortality, and health care utilization after TAVI. Frailty, pre-frailty, and nonfrailty were present in 33% (n = 64), 37% (n = 70), and 30% (n = 57) of patients, respectively. Slowness (75% vs 54%, p = 0.003) and low physical activity (55% vs 31%, p = 0.001) were more common in women than men. With increasing frailty status, the proportion of women increased (35% nonfrail, 44% pre-frail, and 66% frail, p = 0.002) and stature decreased (1.68 ± 0.11 m nonfrail, 1.66 ± 0.11 m pre-frail, 1.62 ± 0.12 m frail, p = 0.028). There was no difference in post-TAVI 30-day mortality, stroke, major vascular injury, major or life-threatening bleeding, respiratory failure, mean hospital length of stay, 30-day hospital re-admission, or overall survival between groups. The rate of discharge to a rehabilitation facility increased with increasing frailty status (14% nonfrail, 22% pre-frail, and 39% frail, p = 0.005). Frailty was independently associated with discharge to a rehabilitation facility (odds ratio 4.80, 95% confidence interval 1.66 to 13.85, p = 0.004). In conclusion, the safety of TAVI is not affected by frailty status, but patients with frailty are less likely to be discharged directly home after TAVI.

Validation of transcatheter aortic valve implantation risk scores in relation to early and mid-term survival: a single-centre study

OBJECTIVES

The aim of this study was to validate recently proposed risk scores for the prediction of mortality up to 1 year after transcatheter aortic valve implantation (TAVI), using a self-expandable valve (CoreValve).

METHODS

In this single-centre study, 225 consecutive patients with severe symptomatic aortic valve stenosis, who underwent TAVI between December 2007 and January 2015, were included. Conventional surgical risk scores (logistic EuroSCORE, EuroSCORE II and STS score) were calculated as well as newly proposed TAVI risk scores (TAVI2-SCORe, STT Score and OBSERVANT score). Medium-term survival of the patients was assessed up to 1 year after TAVI.

RESULTS

The median age was 82 (77-86) years and 45.3% were male. Patients were categorized into 'non-high risk' or 'high risk' according to logistic EuroSCORE >20%, EuroSCORE II >8%, STS score >10%, TAVI2-SCORe >2, STT score >12% and OBSERVANT score >6. Thirty-day and 1-year survival rates were significantly different between 'non-high-risk' and 'high-risk' patients according to the STS score (1 year: low: 84.4% vs high: 67.0%, P = 0.010) and according to OBSERVANT score (1 year: low: 85.2% vs high: 68.4%, P = 0.005). In contrast, TAVI2-SCORe and STT score did not discriminate 'non-high-risk' and 'high-risk' patients. This was confirmed by Cox regression analysis [STS score >10%: hazard ratio: 2.484 (1.206-5.115), P = 0.014; OBSERVANT score >6: hazard ratio: 2.532 (1.295-4.952), P = 0.007].

CONCLUSIONS

In this single-centre study, OBSERVANT and STS score most accurately predicted early and mid-term survival in patients undergoing TAVI, using a self-expandable valve (CoreValve).

Norton scale for predicting prognosis in elderly patients undergoing trans-catheter aortic valve implantation: A historical prospective study

BACKGROUND

The Norton scale is traditionally used to assess the risk of pressure ulcers. However, recent studies have shown its prognostic utilization in elderly patients with diverse medical conditions. The association between low admission Norton scale scores (ANSS), complications, and mortality in elderly patients following trans-catheter aortic valve implantation (TAVI) has never been studied. We aimed to determine if low ANSS (≤16) is associated with complications and 30-day and 1-year mortality in elderly patients undergoing TAVI.

METHODS

The medical charts of elderly (≥70 years) TAVI patients at the Tel-Aviv Medical Center, a tertiary medical center, were studied for the following measurements: ANSS, demographics, co-morbidities, complications during hospitalization, and 30-day and 1-year mortality. Complications included: an atrio-ventricular block, stroke, and vascular complications.

RESULTS

The cohort included 302 elderly patients: 179 (59.3%) were women; the mean age was 83.3±5.1 years. Following TAVI, 112 (37.1%) patients had complications other than pressure ulcers, 10 (3.3%) patients died within 30 days, and 42 (13.9%) patients died within one year. Overall, 36 (11.9%) patients had low ANSS. 1-year mortality rates were almost three times higher in patients with low ANSS relative to patients with high ANSS (27.8% vs. 12.0%; the relative risk 1.1; p=0.018). A stepwise logistic regression analysis showed that ANSS was independently inversely associated with 1-year mortality (p=0.018). Complications and 30-day mortality rates were similar in both groups.

CONCLUSIONS

Low ANSS are associated with 1-year mortality after TAVI. The Norton scale may therefore be used as an additional tool for elderly patient selection before TAVI.

Frailty in cardiothoracic surgery: systematic review of the literature

A preoperative surgical risk analysis is necessary and important for predicting clinical and surgical outcomes in a clinical setting. Various tools for evaluating the patient characteristics in order to forecast perioperative clinical outcomes have previously been described; however, an objective and precise preoperative risk assessment has not yet been established. In the last decade, the concept of frailty, which is a geriatric assessment that identifies disabilities and weaknesses in patients, has been used in order to predict clinical mortality and morbidity following invasive surgical interventions because the prevalence of elderly patients among those undergoing surgical interventions is increasing. Since there is currently no single generally accepted clinical definition of frailty, many clinical modalities are needed to evaluate the patients' geriatric activity of daily living. Quantifying the quality of frailty is an evolving challenge for predicting surgical risks preoperatively. In recent years, with the development of transcatheter aortic valve implantation (TAVI), this newly definitive preoperative surgical risk assessment tool, frailty, has become more important and is attracting interest in cardiothoracic surgical settings. Thus, this review summarized current consideration on the preoperative risk analysis by frailty as well as future perspectives and the potential of an ideal frailty risk assessment in cardiothoracic surgery, including the management of elderly patients and high-risk aortic valve stenosis by TAVI.

Impact of renal dysfunction on mid-term outcome after transcatheter aortic valve implantation: a systematic review and meta-analysis

Background

There is conflicting evidence regarding the impact of preexisting renal dysfunction (RD) on mid-term outcomes after transcatheter aortic valve implantation (TAVI) in patients with symptomatic aortic stenosis (AS).

Methods and results

Forty-seven articles representing 32,131 patients with AS undergoing a TAVI procedure were included in this systematic review and meta-analysis. Pooled analyses were performed with both univariate and multivariate models, using a fixed or random effects method when appropriate. Compared with patients with normal renal function, mid-term mortality was significantly higher in patients with preexisting RD, as defined by the author (univariate hazard ratio [HR]: 1.69; 95% confidence interval [CI]: 1.50–1.90; multivariate HR: 1.47; 95% CI: 1.17–1.84), baseline estimated glomerular filtration rate (eGFR) (univariate HR: 1.65; 95% CI: 1.47–1.86; multivariate HR: 1.46; 95% CI: 1.24–1.71), and serum creatinine (univariate HR: 1.69; 95% CI: 1.48–1.92; multivariate HR: 1.65; 95% CI: 1.36–1.99). Advanced stage of chronic kidney disease (CKD stage 3–5) was strongly related to bleeding (univariate HR in CKD stage 3: 1.30, 95% CI: 1.13–1.49; in CKD stage 4: 1.30, 95% CI: 1.04–1.62), acute kidney injure (AKI) (univariate HR in CKD stage 3: 1.28, 95% CI: 1.03–1.59; in CKD stage 4: 2.27, 95% CI: 1.74–2.96), stroke (univariate HR in CKD stage 4: 3.37, 95% CI: 1.52–7.46), and mid-term mortality (univariate HR in CKD stage 3: 1.57, 95% CI: 1.26–1.95; in CKD stage 4: 2.77, 95% CI: 2.06–3.72; in CKD stage 5: 2.64, 95% CI: 1.91–3.65) compared with CKD stage 1+2. Patients with CKD stage 4 had a higher incidence of AKI (univariate HR: 1.70, 95% CI: 1.34–2.16) and all-cause death (univariate HR: 1.60, 95% CI: 1.28–1.99) compared with those with CKD stage 3. A per unit decrease in serum creatinine was also associated with a higher mortality at mid-term follow-up (univariate HR: 1.24, 95% CI: 1.18–1.30; multivariate HR: 1.19, 95% CI: 1.08–1.30).

Conclusions

Preexisting RD was associated with increased mid-term mortality after TAVI. Patients with CKD stage 4 had significantly higher incidences of peri-procedural complications and a poorer prognosis, a finding that should be factored into the clinical decision-making process regarding these patients.